Provider Demographics
NPI:1710584388
Name:LAKE HEALTH SERVICES, INC.
Entity Type:Organization
Organization Name:LAKE HEALTH SERVICES, INC.
Other - Org Name:LAKE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TIM
Authorized Official - Middle Name:
Authorized Official - Last Name:NGUYEN
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:925-586-2112
Mailing Address - Street 1:PO BOX 7150
Mailing Address - Street 2:
Mailing Address - City:CLEARLAKE
Mailing Address - State:CA
Mailing Address - Zip Code:95422-7150
Mailing Address - Country:US
Mailing Address - Phone:707-994-3141
Mailing Address - Fax:707-994-7150
Practice Address - Street 1:18990 COYOTE VALLEY RD STE 2&3
Practice Address - Street 2:
Practice Address - City:HIDDEN VALLEY LAKE
Practice Address - State:CA
Practice Address - Zip Code:95467-8337
Practice Address - Country:US
Practice Address - Phone:707-994-3141
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LAKE HEALTH SERVICES, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-10-06
Last Update Date:2020-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy